216 Environmental Emergencies
Further Reading
MANAGEMENT
1 Use standard protocols for VF and asystolic cardiac arrest if there is no pulse
or absent respirations (see p. 2).
2 Assess the airway and give high-f low oxygen. Remove smouldering clothing
to prevent secondary thermal injury to skin.
3 Perform early endotracheal intubation to prevent airway obstruction
secondary to soft tissue oedema associated with head and neck burns. Call
for urgent senior ED doctor help.
(i) Ventilatory support is also essential to prevent hypoxic cardiac
arrest secondary to thoracic muscle paralysis.
(ii) Maintain spinal precautions and inline cervical immobilization
during endotracheal intubation and physical examination, as
there is a risk of unrecognized spinal trauma.
4 Commence an i.v. inf usion wit h norma l sa line.
(i) Ensure adequate volume replacement guided by blood pressure,
urine output and the degree of metabolic and respiratory
acidosis.
(ii) Give vigorous fluid resuscitation to maintain urine output
>2 mL/kg per hour to enhance excretion of tissue necrosis
by-products such as myoglobin and potassium from extensive
rhabdomyolysis.
5 Examine for major injuries secondary to a fall and treat accordingly.
6 Admit all patients. Survivors of the initial lightning strike have an excellent
prognosis provided secondary trauma has not occurred.FURTHER READING
American Heart Association (2010) Part 12: Cardiac arrest in special situations:
2010 American Heart Association guidelines for cardiopulmonary resuscita-
tion and emergency cardiovascular care. Circulation 122 : S829–61.
European Resuscitation Council (2010) European Resuscitation Council
Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circum-
stances. Resuscitation 81 : 1400–33.Tip: resuscitate those patients at the scene in cardiac arrest first, the
opposite to a mass casualty disaster, where they would be left for dead
while other patients with survivable injuries are treated as the priority.✓